Make the Most out of Your Non-Cancer Length of Stay Rates

Last October, Palmetto, one of the nation’s largest Medicare Administrative Contractors to the federal government, released their Electronic Comparative Billing Report (eCBR) for 2018 data between April 1 – September 30 that focused on hospice providers’ Non-Cancer Length of Stay (NCLOS) rates. The NCLOS rates provided by the eCBR are important metrics that providers can utilize to become proactive in identifying issues with their billing processes and developing a plan to conduct internal audits to ensure compliance with Medicare guidelines. It can also help providers develop educational opportunities to assist in closing gaps in staff knowledge to avoid potential future challenges.

According to Palmetto, your NCLOS rates are obtained by taking the percentage of your beneficiaries with a length of stay greater than 210 days and a primary diagnosis code billed on the hospice claims within the ICD-10-CM category and comparing them to all your beneficiaries within the same category. NCLOS rates have a range from zero to one. A zero is given when no beneficiaries had lengths of stay greater than 210 days, and one is given when all beneficiaries had lengths of stay greater than 210 days.

Diseases of the nervous system with a length of stay greater than 210 days were the main highlights of the eCBR results. All Palmetto regions had consistently higher lengths of stay in this ICD-10 category, ranging from 26/100 beneficiary stays in the Southeast, 33/100 stays in the Southwest, 31/100 stays in the Gulf Coast, and 28/100 stays in the Midwest.  The diseases of the nervous system are G00-G99 ICD-10 codes, which include commonly seen diagnoses like Alzheimer’s, dementia, Parkinson’s, ALS, and senile degeneration of the brain.

The full grouping of diseases of the nervous system ICD-10 codes are as follows:

The following are useful tips on how to get the most positive impact from your Palmetto NCLOS rates:

1. Look up your personalized NCLOS eCBR results with Palmetto’s e-services to compare and evaluate your risk.
2. Identify beneficiaries on service that have a primary diagnosis in the G00-G99 range and have been on service more than 180 days. It’s recommended to start with 180 days since in the next 30 days they will have met the long length of stay criteria in the eCBR and potentially become reviewable.
3. Implement a review of all records at risk to validate support for hospice terminality in the documentation. This review would also look at whether key documents such as history and physical, initial attending and hospice physician certifications, hospice physician re-certification, and face-to-face attestations are in place.
4. Develop a review tool that looks at documentation. The following are various key questions to keep in mind when conducting documentation reviews:
   • What supported their initial eligibility? Was it an acute event? Was it weight loss/nutrition? Functional decline?
   • What significant co-morbidities do they have affecting their disease process? Are they mentioned?
   • How does their current state compare with their admission? Same? Improved? Decline? How does reported decline compare to admission information? Decline, same or improved?
   • What has happened in the last 6 months to indicate a terminal decline is evident?  Look back 6 months and evaluate whether decline is evident – infections, function, on-call use, symptom management needs, wounds
   • Based on documentation in the narrative summary, face to face (when an assessment tool is used) and clinical notes, would I have admitted them today?  Do they still have evidence of decline?
5. Educate staff that have direct contact with patients on how to document physical, psychosocial and spiritual decline for both the beneficiary and their caregivers. One area that is often missed is the impact on family or caretakers as a disease progresses, which increases the need for services and frequency of calls to the office.
6. Educate staff on the use of scales such as FAST, MAC’s, Girth and PPSv2. Review for inaccurate use of these measures or inconsistent use between team members which makes it difficult to determine if a decline is occurring.
   • i.e., FAST 7C, but is able to have a conversation with spiritual care
7. Have process in place for obtaining admission baseline measures and subsequent comparative measures to provide the team with data for decision making at the interdisciplinary group meetings.
8. Have eligibility discussions at each interdisciplinary group meeting with documentation supporting hospice eligibility decisions evident in the record.
9. Have a process in place for discharging patients who are determined to be on a chronic vs terminal path.
10. If selected for review, ensure submitted documents are complete, consistent, and include information leading up to and after the claim.

Once you review your provider report, you’ll have a better idea of what data Palmetto is seeing for your provider number and can develop an appropriate plan of action specific to your organization if needed. If your organization doesn’t have the resources available to properly utilize Palmetto’s NCLOS eCBR results, consider using a third-party consulting firm like McBee to develop a plan and resources, conduct off-sites reviews, and educate your staff.